Comparison of quality of life in patients with mitral valve replacement and mitral valve repair in Imam Ali Hospital during 2014 to 2020: a cross-sectional study

Objective Mitral valve failure is one of the most common valvular heart diseases worldwide. Valve replacement and repair have an impact on the quality of life of patients. Therefore, the present study was conducted to compare the quality of life in patients with mitral valve replacement and those who underwent mitral valve repair. Methods In this cross-sectional study, we considered all cardiac patients with ischemic mitral insufficiency who underwent mitral valve repair and patients with a history of valve replacement in Imam Ali Hospital of Kermanshah between 2014 and 2020. Two Minnesota and general quality of life questionnaires along with a checklist for demographic variables were used for data collection. Data analysis was performed using SPSS version 21 software. Results The mean quality of life score based on the general quality of life scale in the valve repair group was 32.33 (SD = 2.29) and in the valve replacement group 32.89(SD = 2.60), (p = 0.917). Also, mean quality of life, as measured by the Minnesota MLHFQ was 60.89(SD = 17.67) in the valve repair group and 63.42 (SD = 12.13) in the valve replacement group (p = 0.308). The results showed that the average general quality of life was different in study groups regarding education. Tukey’s post hoc test showed that the average general quality of life in illiterate people is significantly lower than in people with academic degrees (P-value = 0.001). Conclusion The quality of life of the patients in both the valve repair and replacement groups was at an average level. There was no significant difference between the general quality of life and the Minnesota scales, suggesting that both tools can be effectively used to measure patients’ quality of life. The study’s findings can be valuable for monitoring patients, screening for conditions, and enhancing communication between doctors and patients.


Introduction
The global epidemiology of valvular heart disease has undergone significant changes over the past century [1].According to the Global Burden of Disease Study (2018), calcific aortic valve disease and degenerative mitral valve disease resulted in the loss of 1.5 million and 1.1 million DALYs (disability-adjusted life years) worldwide, respectively.These figures represent 0.12% of the total health loss in 2017 [2].However, in certain countries like Iran, the burden of non-rheumatic valvular heart disease remains largely unknown and is not considered a major public health concern.Previous research has primarily focused on the burden of ischemic heart disease, heart failure, and other cardiovascular conditions [3][4][5].Mitral valve insufficiency is one of the most common types of heart valve disorders.It occurs when the mitral valve fails to close properly, causing blood to flow back into the upper chamber (atrium) when the left ventricle contracts [6].There are several treatment methods to treat people with mitral valve insufficiency, including drug treatment, valve replacement, and valve repair.For individuals with symptomatic mitral valve insufficiency, surgery should be performed.Nearly 250,000 heart surgeries are performed every year, some of which include valve replacement surgery [7,8].
When it comes to the treatment of mitral valves, the decision to repair or replace them is often a challenging one for both surgeons and patients.One factor that can greatly assist in this decision-making process is the consideration of health-related quality of life [9][10][11][12][13].
Restrictions caused by mitral valve repair or replacement make the patient's work, family, and social life difficult which causes social isolation and depression [14,15].Problems such as reduced ability to perform responsibilities, inability to perform duties (58%), and weakness and fatigue (51%) are among its consequences, which affect the quality of life of patients [16].The World Health Organization (WHO) defines quality of life as a person's understanding of their place in life in the context of the cultural system and the values in which she lives, which are related to her goals, expectations, standards, and concerns.The situation of each person is complexly influenced by physical health, psychological status, personal beliefs, and social relationships [7,17].
Studies on quality of life are valuable to both patients and surgeons, as they may provide important information in the process of shared treatment decision-making [18].For instance, Martenson and colleagues assert that the primary source of depression and unfavorable quality of life in these patients is attributed to multiple physical symptoms resulting from the disease [19].The disease and intolerance of activity cause physical symptoms, leading to social isolation and disturbances in patients' sexual relations.Consequently, their roles in family and social life are altered, ultimately reducing their life satisfaction.In addition, the need to take certain drugs, such as diuretics, disrupts the patients' social relations and negatively impacts their social quality of life [20].Poor physical performance and depression contribute to an impaired quality of life in these patients [21,22].Davranovna et al. (2022) concluded that the quality of life for these patients is suboptimal, which is associated with the presence of anxiety/depression, with the most significant limitations observed in the physical and functional aspects of their quality of life [23,24].According to a study by Blokzijl et al. (2021), it's important to talk about quality of life before surgery, especially for older patients undergoing aortic valve replacement.The study found that older age is linked to a lower quality of life after surgery.This suggests that discussing quality of life during preoperative counseling could help manage expectations and support patients better [25].Also, the quality of life after mitral valve surgery was reported to be suboptimal in more than half of the elderly patients [26].A poor quality of life not only has a negative effect on social life, family, work, and recreational activities but also increases the risk of hospitalization and death caused by this disease [27,28].
The quality of life of heart patients is often measured using different tools, but there is no agreement on the best methods for assessment.Moradi et al. (2020) conducted a systematic review and meta-analysis to investigate the quality of life (QOL) of patients with chronic heart failure (CHF).Their analysis, which included data from 40 studies involving 12,520 patients, revealed a mean QOL score of 44.1.Notably, the study found that CHF patients in the Americas exhibited higher QOL scores compared to those in other geographical regions.Based on this study, It's important to regularly measure the quality of life of patients using appropriate tools as part of their overall care [29].A review by Adebayo in 2017 found that quality of life (QOL) is effective in predicting negative outcomes in heart failure (HF).QOL's ability to assess and predict outcomes in HF is similar to traditional HF assessment tools like 6MWT, B-type natriuretic peptide, LVEF, and NYHA class [30].Saccomann (2010) studied the quality of life of elderly people with heart failure using a standard questionnaire (SF-36).The study found that this questionnaire is reliable for measuring the quality of life of elderly individuals with heart failure [31].Although limited studies have been carried out in this field, the wide range of definitions and dimensions of quality of life shows the importance of conducting new research on the topic [32].Therefore, the present study was conducted to investigate and compare the quality of life of patients who underwent valve replacement with those who underwent mitral valve repair at Imam Ali Hospital in Kermanshah city between 2014 and 2020.To gain insights into the quality of life of the patients, the study utilized two questionnaires: the Quality-of-Life Questionnaire (SF36) and the Minnesota questionnaire.These tools are designed to comprehensively evaluate various aspects of an individual's well-being, including physical health, mental health, and overall quality of life.By employing these questionnaires, the study aimed to gather a comprehensive understanding of the impact of valve replacement and mitral valve repair on the patients' lives.Additionally, the results from these scales were compared.Comparing the results from the SF-36 and the Minnesota questionnaire holds immense value in understanding and addressing the complex interplay between overall health and cardiovascular well-being.The decision to focus solely on ischemic mitral insufficiency patients is justified by the diverse nature of heart diseases, each with its unique characteristics and implications.Ischemic heart failure stands out as a significant contributor to morbidity and mortality.To gain a deeper understanding of the impact of ischemic heart failure on patients' quality of life, it is crucial to focus on specific subgroups within this population.By narrowing down the study population to a specific subgroup, researchers can delve deeper into the nuances of this condition and offer tailored solutions to enhance patient care and well-being.The results of this study are anticipated to fill a crucial gap in the existing literature on heart diseases, particularly ischemic mitral insufficiency.

Study design
The present study was a cross-sectional study that was conducted with the aim of comparing the quality of life in patients with ischemic mitral regurgitation, including patients with mitral valve replacement and mitral valve repair.

Study area and period
This study was conducted among patients with mitral valve replacement and mitral valve repair referred to Imam Ali Hospital of Kermanshah (a megacity in the western spot of Iran) during 2014-2020.Imam Ali Hospital is the largest referral cardiovascular center in the west of Iran and the first center of cardiovascular surgery and angiography.The hospital includes different wards like, emergency, ICU, CCU, post-ICU, angiography, echocardiography, radiology, operating rooms, laboratories, rehabilitation centers, pharmacies, etc.

Study population
The statistical population of the study included all cardiac patients suffering from ischemic mitral insufficiency who underwent mitral valve repair or replacement in Imam Ali Kermanshah Hospital between 2014 -September 2020, and a total of 300 patients who were refered to the hospital during the study period and were eligible based on the following inclusion and exclusion criteria (150 mitral valve repair and 150 valve replacement patients) were included in the study.

Inclusion and exclusion criteria
After obtaining approval from the ethics committee and obtaining a written consent form from the patients, and compliance with maintaining respondent data confidentially to protect the privacy of human subjects while collecting, analyzing, and reporting data, following inclusion and exclusion criteria were considered.People over 18 years of age with moderate to severe mitral ischemic mitral regurgitation were included in the study with informed consent.The exclusion criteria were as follows: patients with mild/mild to moderate mitral valve insufficiency; patients with a non-ischemic cause for mitral valve insufficiency (rheumatic cause, etc.); the coexistence of other mitral valve diseases (mitral stenosis, mitral valve prolapse, etc.); concomitant valve diseases other than mitral (aortic and tricuspid valve stenosis or insufficiency, etc.), history of any previous manipulation of the mitral valve; patients with congenital heart disease; patients with perforation of the interventricular wall due to acute heart attack; and people diagnosed with acute physical and mental disorders such as (cancer, MS, schizophrenia, etc.) were excluded.

Data collection, instruments and procedure
The data was gathered in two stages from 300 patients referred to Imam Ali Hospital.In the first step, information was gathered by referring to the files and analyzing the patients' files, and then the patients were called, and after describing the research aims, they were either asked questions about their quality of life based on the questionnaires or a link to the questionnaire was delivered to them.In some cases, the patients were referred in person, and the questionnaire questions were asked and completed.In order to accurately collect data, trained nurses extracted information from the case and asked questionnaire questions.In order to increase accuracy in answering, questions were asked of the patients when they had the patience to answer them.The collected data were checked for completeness, and outliers and distorted data were removed.Using descriptive statistics, including frequency and percentage, background information was provided.Skewness indices were employed to check for normality.Skewness indices were employed to check for normality.As the data distribution was normal, an analysis of variance and an independent t-test were performed to compare the results from the SF-36 and the Minnesota questionnaires in the invalve repair and replacement groups.Also, the average quality of life of the studied patients was evaluated based on demographic variables, and a Tukey post hoc test was used to find out which specific groups's means are different.For quantitative data analysis, SPSS-21 statistical software was employed.For all analyses, a significance level of 0.05 was considered.
In order to collect data, the data collection form includes demographic information such as age, gender, level of education, income, smoking, and etc.; a special Minnesota quality of life questionnaire for heart failure patients; and a 36-question general quality of life questionnaire.Quality of life questionnaire with 36 questions (SF-36): The 36-question quality of life questionnaire (SF-36) contains 36 questions and 8 subscales, with each subscale including 2 to 10 items.The eight subscales of this questionnaire are: physical function (PF), role disturbance due to physical health (RP), role disturbance due to emotional health (RE), energy/fatigue (EF), emotional well-being (EW), social functioning (SF), pain (P), and general health (GH).In addition, the integration of the subscales yields two general subscales; physical health and mental health.The lowest possible score is 26 and the greatest possible score is 130.A lower score on this scale indicates a lower quality of life, and vice versa [33].Cronbach's alpha was 75%, and the reliability coefficient was 81%.
Minnesota Quality of Life Questionnaire MLHFQ: Rector (1984) developed this questionnaire to assess the impact of treatment on the quality of life of patients with heart failure.This scale is the most commonly used tool in heart failure research to assess patients' comprehension of the impact of CHF on the physical, economic, social, and psychological elements of their lives.There are two subscales and 21 items in this questionnaire.It has two subscales: physical and emotional.Internal consistency analysis and the retest approach were used to verify the instrument's reliability.Cronbach's alpha was 95%, and the test-retest reliability coefficient (ICC) was greater than 90% in all areas in two implementations two weeks apart [33].

Results
Of the 300 studied populations, 116 were men (35.2%) and 184 were women (55.8%).The average age of women, 58.16 (SD = 10.66), was slightly higher than that of men, 52.16 (SD = 10.62)(Table 1).The highest prevalence of concomitant diseases observed was 47.6% for heart failure in the valve repair group and 39% for angina in the valve replacement group; more details of demographic characteristics and underlying medical conditions are provided in Table 1.
According to the results of Table 2, the average score of the general quality of life questionnaire in the valve repair group it was 32.33(SD = 2.29) and in the valve replacement group was 32.89 (SD = 2.60).There was no significant difference observed (p = 0.917).According to this scale, both groups had an average quality of life (the higher the average score, the higher the quality of life, and the range of 25-36 is average quality of life).The mean quality of life of Minnesota MLHFQ was 60.89 (SD = 17.67) in the valve repair group and 63.42 (SD = 12.13) in the valve replacement group, with no significant difference (p = 0.308).The higher the average score, the lower the quality of life, and the range of 36-70 is the average quality of life.
The average quality of life (general quality of life and Minnesota quality of life) in the studied patients was evaluated based on demographic variables, and the results showed that the average score of the general quality of life questionnaire was higher in men (34.68 (SD = 2.81)) than women (29.52 (SD = 2.75)).Also, the results of the Tukey post hoc test showed that the average quality of life score of illiterate people is significantly lower than that of people with academic degrees, and the difference between them is significant (P-value = 0.001) (Table 3).

Discussion
In this study, we provided evidence comparing the quality of life in patients who underwent mitral valve replacement and those who underwent mitral valve repair.Studies have shown that patients undergoing heart surgeries have expectations of the surgical results.These include prolonging life, improving quality of life, increasing the strength of exercise and activity, and pain relief, which has been reported to improve health and relieve pain after surgery in most patients, but no extensive studies have been conducted in the field of quality of life.Studies in the quality of life field can provide the basis for their further recovery by anticipating their needs and making necessary interventions [34].In fact, data of the quality of life, in addition to helping provide effective treatment, also contributes to the improvement of support programs and rehabilitation measures.Therefore, the present study was conducted with the aim of comparing the quality of life in patients with mitral valve replacement and mitral valve repair in Imam Ali Hospital during 2014-2020.
The results of the present study indicate that the quality of life for both the valve repair and replacement groups was average using specific and general tools.Also, there was no significant difference in the quality of life between the valve repair and valve replacement groups.This finding is in line with the results of a study conducted by Jokinen et al. which reviewed 184 patients who underwent mitral valve replacement or repair.Their study found that there was no difference in the quality of life between the valve repair and valve replacement groups [35].The differences may be due to the extent of the disease, with patients undergoing valve replacement often having a history of left heart failure and showing preoperative enlargement of the left atrial and left ventricle sizes compared to those undergoing valve repair.Additionally, fibrillation is more common in valve replacement compared to valve repair groups [9,37].

Immer et al. compare the quality of life in valve repair and valve reconstruction qropus and reported that the
Although the level of quality of life for patients who undergo valve repair and replacement is reported as average, the results of the present study indicate a difference in the quality of life between the two sexes.Specifically, men reported a higher quality of life compared to women.The study by Abbasi et al. (2016), "Investigation of the Quality of Life of Patients with Heart Failure, " found that gender has a significant impact on the quality of life for patients with heart failure.Men generally experience a better quality of life than women in this context, as indicated by all three dimensions and the overall average quality of life [38].Shojaei et al. (2008) reported that a significant relationship was observed between gender and quality of life in valvular heart patients, with men having a better quality of life [39].It seems that the increased presence of men in society, resulting from their employment, wider range of friendships, and higher social status compared to women, plays a role in this matter.Additionally, men generally enjoy better economic status, which can have a positive impact on the reporting of a higher quality of life.On the other hand, numerous studies have shown that physical activity significantly influences the quality of life, regardless of whether individuals are healthy or affected by various diseases [39,40].It appears that society has provided men with more opportunities for physical activity compared to women, resulting in limitations for women in this regard.Moreover, women consistently experience higher rates of depression than men, not only until retirement age but potentially throughout their lives, which can significantly impact their quality of life [41].
In the present study, education was one of the significant variables related to the quality of life of patients.The average quality of life (36 questions) of illiterate people is significantly lower than in people with an academic degree.Consistent with the present study results, Saber Azami-Aghdash et al. (2019), conducted a cross-sectional analytical study in 2017, where 180 patients were selected and data the collection tool was the WHO quality of life questionnaire.They reported that there is a significant relationship between education level and quality of life [42].Studies have shown that people with a higher level of education have a better quality of life.The results of Abbasi et al. 's study also confirm that the relationship between the level of education and different dimensions of quality of life, as well as the average overall quality of life, is significant [38].People with university degrees tend to have a better quality of life compared to other individuals [43].This can be attributed to various factors, such as a shift in attitude and lifestyle towards health and illness, as well as other aspects of life.Higher education may also lead to better social welfare, social status, and improved economic conditions, all of which contribute to a higher quality of life.In the present study, quality of life were assessed using two 36-question general quality of life questionnaires and a specific Minnesota quality of life  questionnaire.The results from this study indicate that there was no significant difference in the average quality of life score between the valve repair and replacement groups, as measured by the Minnesota MLHFQ and the 36-question quality of life assessment.The findings align with previous research.A 2017 review Adebayo suggests that QOL effectively predicts negative outcomes in heart failure (HF), similar to traditional HF assessment tools, and Saccomann's 2010 study using the SF-36 questionnaire demonstrated its reliability in assessing the QOL of elderly Brazilians with HF [30,31].The present study has limitations to consider; using questionnaires can lead to unreliable data.The study's population wasn't representative of all cardiac patients, so the findings should be generalized with caution.It only focused on hospital participants and didn't assess their prior mental status, which could impact the results.

Conclusion
The present study was conducted to compare the quality of life in patients with mitral valve replacement and those who underwent mitral valve repair.Based on the results, the quality of life for both the valve repair and replacement groups using specific and general tools was found to be at an average level.The high reliability of the SF-36 and MLHFQ among this population is an important point to be taken into account in choosing instruments for evaluating quality of life.Other results of the study revealed that gender and education level emerged as variables that exhibited a significant correlation with the quality of life of patients.Furthermore, age, marital status, and education level were also identified as variables that demonstrated a significant relationship with patients' quality of life.The results of the presnt study are useful in identifying the factors affecting the quality of life of the patients and suggest clinicians encourage the assessment of quality of life to facilitate patient-centered care to improve the health and quality of life of mitral valve patients.Quality of life assessement help policymakers and decision makers make evidence-based decisions by considering priorities, more efficient allocation of resources, and opportunities needed to improve patients' quality of life.

Table 1
Demographic characteristics of the studied subjects (n = 300)

Table 2
Average quality of life score of 36 questions and Minnesota MLHFQ quality of life in the studied patients

Table 3
Average quality of life scores in the participants by gender and education